Careone At Oradell
Inspection history, citations, penalties and survey trends for this long-term care facility in Oradell, New Jersey.
- Location
- 600 Kinderkamack Road, Oradell, New Jersey 07649
- CMS Provider Number
- 315339
- Inspections on file
- 17
- Latest survey
- December 13, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Careone At Oradell during CMS and state inspections, most recent first.
A resident at high risk for pressure ulcers developed an unstageable pressure injury on the right hip due to inadequate assessment and documentation by the facility's nursing staff. Despite the resident's severe cognitive impairment and high Braden scale score, the facility failed to document or address the skin condition effectively, leading to the progression of the wound. The facility did not notify the physician promptly or initiate a care plan, and discrepancies in documentation practices further contributed to the deficiency.
The facility failed to update its facility-wide assessment, leading to inadequate supplies such as linens and incontinence pads. Residents and CNAs reported shortages, impacting care. Management was unable to provide an updated assessment or plan to address these deficiencies.
The facility was found deficient in maintaining a clean and homelike environment. Observations included dust and debris on air vents, unclean shower rooms with debris on the floor, and a resident's room with dried substances and dust accumulation. Staff confirmed the lack of regular cleaning, and no documentation was available to verify maintenance of cleanliness.
The facility failed to administer medications as scheduled for a resident and two other residents. A resident did not receive Alprazolam for several days due to unavailability and lack of communication with the pharmacy. Two other residents reported receiving their medications late, affecting their treatment for dizziness and other conditions. The facility's records confirmed these delays, which were not documented as per policy.
A resident reported receiving only one shower per week, contrary to the scheduled two showers, impacting their dignity and quality of life. Discrepancies were found between the shower schedule and documentation, with staff providing conflicting information. The facility's policies emphasize maintaining residents' abilities in daily activities, but the failure to adhere to the schedule resulted in a deficiency.
A facility failed to prevent a potential medication interaction by administering sodium bicarbonate and ferrous sulfate simultaneously to a resident, despite known interaction risks. The resident, with a history of anemia and other conditions, received these medications together, potentially reducing the absorption of ferrous sulfate. The facility's policy emphasized timing to prevent interactions, but this was not adhered to, and previous recommendations to separate these medications were not applied.
A facility failed to ensure proper respiratory care for a resident with COPD, as oxygen therapy was not administered according to the physician's order or documented in the eTAR. The resident was observed receiving continuous oxygen, despite a PRN order for use when oxygen saturation levels fell below 92. The LPN confirmed the continuous use, influenced by the resident's family, and the DON was notified. A handwritten order was later provided, but it was not reflected in the electronic medical record, and the facility did not clarify the order as required by their policy.
The facility failed to provide sufficient nursing staff, leading to inadequate care for residents. A resident reported being left on the toilet for an extended period due to staffing shortages, and staff interviews confirmed that aides were overburdened, especially on weekends. The facility consistently failed to meet state-mandated staffing ratios, and despite being aware of the issue, management had not implemented effective solutions.
The facility failed to accurately post the Nursing Home Resident Care Staffing Report (NHRCSR) and resident census at the beginning of shifts on two occasions during a survey. On one occasion, the report was outdated due to an oversight by the weekend receptionist, and on another, there was a discrepancy in the census numbers. The SC, DON, and LNHA were informed of these issues, which violated the facility's policy.
The facility failed to properly store and label medications, as observed by a surveyor. Two medication carts contained vials of blood glucose testing strips without the date of opening, and the central supply stock room was found unlocked with expired medications present. The DON acknowledged the expired medications and removed them for disposal. The facility's policy requires locked storage and proper handling of expired medications, which was not followed.
The facility failed to offer and document pneumococcal and influenza vaccinations for four residents, including those with cognitive impairments. Despite policies requiring vaccine offers within five days of admission, documentation was missing or incomplete. Interviews with staff revealed inconsistencies in the vaccination process, with the current IP struggling to update records after the previous IP's leave.
A resident with severe cognitive impairment and multiple diagnoses was affected when the pharmacy sent Anagrelide 1 mg instead of the ordered Anastrozole 1 mg. Nursing staff documented administration of the correct medication, but pharmacy shipping records showed repeated deliveries of the incorrect drug. Nurses failed to verify the medication against the physician's order upon receipt, resulting in the wrong medication being available for administration.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care to prevent and manage pressure ulcers for a resident, leading to the development of an unstageable pressure injury on the right hip. The resident, who was at high risk for pressure ulcers due to severe cognitive impairment and other medical conditions, was not properly assessed or monitored for skin impairments. Despite having a Braden scale score indicating high risk, the facility did not document or address the resident's skin conditions effectively, resulting in the progression of a pressure injury to an unstageable wound with slough and serosanguineous drainage. The facility's nursing staff did not follow professional standards of practice in assessing and documenting the resident's skin condition. There was a lack of documentation regarding the initial identification and measurement of the right hip wound, and the facility failed to notify the physician promptly. The wound was only identified during routine wound rounds by a consultant, and there was no evidence of a care plan being initiated to address the pressure injury. The nursing staff also failed to follow the physician's advice to consult a wound doctor for the right hip pressure wound. Additionally, the facility's documentation practices were inadequate, with discrepancies in the records and late entries that did not accurately reflect the resident's condition. The RN/UM admitted to missing the initiation of a care plan for the pressure ulcer, and the DON acknowledged a knowledge deficit among the nursing staff in assessing and describing wounds. The facility's failure to adhere to its own policies and procedures for pressure ulcer prevention and management contributed to the deficiency.
Facility-Wide Assessment and Supply Shortages
Penalty
Summary
The facility failed to ensure that a facility-wide assessment was reviewed and updated to identify the required services and procedures necessary to protect the health, safety, and welfare of all residents. This deficiency was evidenced by the lack of adequate supplies, such as linens and incontinence pads, which were insufficient to meet the needs of the residents. During the survey, it was observed that the facility's par levels for supplies were not updated or aligned with the current census, leading to a shortage of essential items for resident care. Interviews with residents and staff revealed that the facility often ran short on necessary supplies. Residents reported that gowns and incontinence pads were sometimes unavailable when needed. Certified Nursing Aides (CNAs) confirmed these shortages, stating that the supplies they received were insufficient for the number of residents they were assigned to care for. The CNAs had to rely on leftover supplies from previous shifts or wait for deliveries, which impacted their ability to provide timely and adequate care. The facility's management, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), were unable to provide an updated Facility Assessment (FA) that included the necessary par levels for supplies. Despite being aware of the supply issues, the management did not have a clear plan or documentation to address the deficiencies. The lack of an updated FA and the failure to adjust supply levels according to the resident census contributed to the ongoing supply shortages, affecting the quality of care provided to the residents.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several observations made by the surveyor. On the 2nd floor nursing units, a gray, dust-like substance was found adhering to air circulation vent covers in both the 2 North and 2 South units. The Housekeeping Supervisor and Director of Maintenance confirmed that the vents were not clean and should have been regularly maintained. Additionally, there was no documentation available to verify regular cleaning of these areas, indicating a lapse in housekeeping protocols. In the 2 South nursing unit's shower room, the surveyor observed vinyl gloves, debris, and a shampoo bottle on the floor, along with various equipment such as lifts and wheelchairs. The floor was dry, suggesting it had not been recently cleaned. A Licensed Practical Nurse confirmed that the floor was not clean and that items should not be left on the floor. Furthermore, a resident reported a stain on the shower room floor, which was cleaned by a nursing aide before the resident's shower. Resident #94's room was found to have dried brownish and whitish substances on the floor and nightstand, along with an accumulation of dust and debris around the heater and windowsill. The resident's representative confirmed that these conditions had persisted for days. The surveyor noted that the facility's Cleaning and Disinfection of Environmental Surfaces Policy was not being followed, as regular cleaning and disinfection were not documented or evident in the observed areas.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that a resident's medication was available and administered as scheduled, as well as failed to administer medications on time for two other residents. For Resident #66, the medication Alprazolam was not available and not administered for several days. Despite the resident being alert and having no immediate concerns, the medication was crucial for managing their anxiety and restlessness at night. The facility's records showed multiple instances where the medication was not dispensed, and there was a lack of communication with the pharmacy and physician to resolve the issue promptly. For Resident #87, there were concerns about not receiving morning medications at the scheduled time, which affected their management of dizziness. The resident reported receiving medications late on several occasions, which was confirmed by the facility's medication administration records. The records indicated that medications were administered outside the scheduled timeframe, and there was no documentation explaining the delays. Similarly, Resident #79 experienced delays in receiving both morning and evening medications. The resident reported late administration of medications on multiple occasions, and the facility's records corroborated these claims. The facility's policy required medications to be administered within one hour of the scheduled time, but this was not adhered to, and there was insufficient documentation to justify the delays.
Failure to Honor Resident's Shower Schedule and Preferences
Penalty
Summary
The facility failed to honor a resident's shower schedule and preferences, impacting their dignity and quality of life. Resident #52, who was alert, oriented, and independent with activities of daily living, reported receiving only one shower per week for the past couple of weeks, despite being scheduled for two showers weekly. The resident expressed dissatisfaction with the frequency of showers, indicating a preference for more frequent bathing. During the survey, discrepancies were found between the shower schedule and the actual documentation in the electronic medical record (EMR). The Registered Nurse/Unit Manager (RN/UM) and Certified Nurse Aides (CNAs) provided conflicting information about the shower schedule and documentation process. CNA #2, responsible for Resident #52, was unaware of the shower schedule binder and had not taken any residents for showers on the day of the survey. The EMR review revealed a lack of documentation for the resident receiving routine showers twice a week as scheduled. The facility's policies on Activities of Daily Living and Resident Rights emphasize the importance of providing appropriate care and services to maintain or improve residents' abilities to carry out daily activities, including hygiene. However, the failure to adhere to the shower schedule and document the care provided resulted in a deficiency in treating the resident with respect and dignity, as required by federal and state laws.
Failure to Prevent Medication Interaction
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by administering two potentially interacting medications simultaneously to a resident. During a medication pass observation, a Licensed Practical Nurse (LPN) administered sodium bicarbonate and ferrous sulfate to a resident at the same time, despite the potential for decreased absorption of ferrous sulfate when taken concurrently with sodium bicarbonate. The resident's medical records indicated a physician's order for ferrous sulfate to be taken three times daily for anemia, with instructions to avoid certain substances within two hours, and sodium bicarbonate to be taken twice daily. The surveyor noted that the electronic medical administration record (eMAR) and pharmacy notifications could alert staff to potential drug interactions, but this was not utilized effectively in this instance. The resident involved had a medical history that included hypercalcemia, chronic kidney disease stage 4, and anemia. A review of the facility's medication administration policy highlighted the importance of timing medications to prevent interactions, but this was not followed. Additionally, a Consultant Pharmacist (CP) report for another resident had previously recommended separating iron products from sodium bicarbonate by at least two hours, but this recommendation was not reflected in the CP admission review report for the resident in question. The deficiency was identified as a repeat issue, indicating ongoing non-compliance with professional standards of medication administration.
Failure to Ensure Proper Oxygen Therapy Documentation and Administration
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident receiving oxygen therapy, as per the physician's order and facility policy. The deficiency was identified through observations, interviews, and record reviews. A resident with severe cognitive impairment and a diagnosis of chronic obstructive pulmonary disease (COPD) was observed receiving oxygen therapy at 2 liters per minute (LPM) via nasal cannula, which was not properly documented in the electronic Treatment Administration Record (eTAR) for November and December 2024. The resident's care plan indicated a risk for respiratory impairment, and the physician's order specified oxygen use as needed (PRN) for oxygen saturation levels below 92, yet there was no documentation of such use. The Licensed Practical Nurse (LPN) confirmed that the resident was on continuous oxygen, contrary to the PRN order, and mentioned that the resident's family wanted the oxygen on all the time. The Director of Nursing (DON) was informed of the issue, and a handwritten physician order was provided after the surveyor's inquiry, indicating a change in oxygen delivery at different times of the day. However, this order was not reflected in the resident's electronic medical record, and the facility did not provide further documentation to clarify the order. The facility's Oxygen Administration Policy requires verification of a physician's order and documentation of the procedure, which was not adhered to in this case.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. A resident reported being left on the toilet for about half an hour due to a lack of available aides, and the resident council minutes confirmed a similar incident where the resident waited for assistance. The facility's staffing issues were particularly pronounced on weekends, with aides being spread too thin and unable to provide timely care. Interviews with staff revealed that the facility was consistently understaffed, especially on weekends, with aides having to care for more residents than the state-mandated ratios. The staffing coordinator acknowledged the challenges in maintaining adequate staffing levels, citing a loss of aides and difficulties in recruiting replacements. Despite efforts to call in additional staff, the facility did not offer bonuses or utilize agency staff to fill the gaps, leading to ongoing staffing shortages. The facility's staffing records for the two weeks prior to the survey showed consistent deficiencies in CNA staffing levels, failing to meet the required ratios on all day shifts. The facility's policy on providing sufficient and competent nursing staff was not adhered to, resulting in inadequate care for residents. The Director of Nursing and the Licensed Nursing Home Administrator were aware of the staffing issues but had not implemented effective solutions to address the deficiencies.
Inaccurate Staffing and Census Reporting
Penalty
Summary
The facility failed to ensure the accurate daily posting of the Nursing Home Resident Care Staffing Report (NHRCSR) and resident census at the beginning of the current shift for two out of six days during the annual re-certification survey. On 12/2/24, the surveyor observed that the NHRCSR posted at the front desk was dated 11/30/24, and there was no report for 12/2/24. The Staffing Coordinator (SC) acknowledged that the correct report was not posted due to an oversight by the weekend receptionist, who failed to update the report. The full-time receptionist corrected the error after the surveyors entered the facility. Additionally, on 12/5/24, there was a discrepancy in the census numbers on the NHRCSR, which did not match the Nursing Census Sheet and assignments for the two units. The SC was unable to explain the incorrect census, noting that corrections are typically made by the night shift or upon her arrival in the morning. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were informed of these inaccuracies, which were in violation of the facility's policy requiring the posting of direct care daily staffing numbers for every shift.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications in accordance with its policy and standard clinical practice. During an inspection, a surveyor observed that two medication carts, labeled Cart 3 and Cart 4, contained vials of blood glucose testing strips that did not have the date of opening marked on them. The medication nurse confirmed that the vials should have been dated when opened. Additionally, the central supply stock room on the first floor was found unlocked, and within it, a metal cabinet containing stock medications was also unlocked. Expired medications, including bottles of Folic Acid and Aspirin, were found in the stock and were acknowledged by the Director of Nursing (DON) as expired and subsequently removed for disposal. The facility's policy on medication labeling and storage requires that all medications and biologicals be stored in locked compartments and that expired or discontinued medications be handled according to instructions from the dispensing pharmacy. The surveyor's findings indicated a failure to adhere to these policies, as evidenced by the unlocked storage areas and the presence of expired medications. The surveyor attempted to contact the facility's Consultant Pharmacist for further information but did not receive a response.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal and influenza vaccines to four residents, as well as document refusals or reasons for ineligibility. Resident #42, admitted with an intact cognitive status, had no documentation of influenza vaccination assessment or offer in their medical records. Interviews with the LPN and RN/UM revealed a lack of documentation and acknowledgment of missing vaccine information, despite the facility's policy to offer vaccines within five days of admission. Resident #66, with moderate cognitive impairment, had no documentation of being offered the flu vaccine for the 2024-2025 season until after surveyor inquiry. The DON confirmed that the previous Infection Preventionist had initiated flu vaccinations, but due to their leave, the current IP was trying to catch up, resulting in incomplete immunization records and delayed vaccine offers. Residents #94 and #197, both with severely impaired cognitive skills, had no documented evidence of being offered influenza or pneumococcal vaccines. The IPN, responsible for tracking and offering vaccines, confirmed the absence of consent forms and documentation in the medical records. The DON acknowledged the deficiency, stating that immunizations should be part of the admission process, with documentation of offers and refusals.
Incorrect Medication Delivered and Administered Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
The facility failed to provide the correct medication to a resident according to the physician's order when the pharmacy sent the wrong medication. A resident with a history of malignant neoplasm of the left breast, cerebral infarction, altered mental status, osteoarthritis, muscle weakness, and anxiety disorder, and who was totally dependent on staff for activities of daily living and had severely impaired cognition, was affected by this deficiency. The physician's order specified Anastrozole 1 mg tablet to be administered daily for post-breast cancer care, but the pharmacy erroneously sent Anagrelide 1 mg capsules instead. The medication administration records indicated that nursing staff documented the administration of Anastrozole as ordered, but shipping manifests from the pharmacy showed that Anagrelide was delivered to the facility on multiple occasions for the resident. The error was discovered when a registered nurse found Anagrelide in the medication cart and reported it to the previous DON. The nurse confirmed that there were no other residents prescribed Anagrelide at that time. The facility's investigation and pharmacy occurrence report confirmed that the pharmacy entered and shipped the wrong medication, and the nurses receiving the medication did not reconcile it against the resident's current medication orders as required by facility policy. Facility policy required licensed nurses to verify medications received from the pharmacy against the original medication order and ensure proper storage. However, the nurses who received and signed for the medication deliveries failed to perform this verification, resulting in the wrong medication being available for administration to the resident. This oversight led to the administration of a medication not ordered by the physician, as evidenced by the pharmacy shipping manifests and the facility's internal investigation.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
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